CLM-2026-007943
Riverside Cardiovascular Associates, Cardiology. Service 2025-11-02 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Thomas Matthews
- Member ID
- UHC-26458-46
- Date of birth
- 1986-10-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404786
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9415
- Coverage period
- 2024-04-01 to present
- Deductible
- $92.25 of $500.0018%
- Out-of-pocket maximum
- $261.87 of $1,500.0017%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 1464599905
- Location
- Atlanta, GA · TIN 37-2658699
- Authorisation / referral
- PA2026260690 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,177.00 | $3,947.35 | — | — | DeniedCO29 |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 1,2 | $619.00 | $340.45 | — | — | DeniedCO29 |
| Totals | $7,796.00 | $4,287.80 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-752029
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013524 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-02: N/A (PPO), effective 2024-04-01. | |
| Timely filing | Fail | CO29 | Received 106 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026260690 on file for 93458. | |
| Provider network | Pass | In-network provider Riverside Cardiovascular Associates (4236552608). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Cardiovascular Associates2025-11-02 17:55
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-16 03:48
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-16 09:08
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026260690_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-11-02 to 2026-01-31.
- Itemized billitemized_PA-752029.pdf9 pages
Itemised statement totalling $7796.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 106 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.